Healthcare Provider Details

I. General information

NPI: 1659984052
Provider Name (Legal Business Name): MADISON RAE TARE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 GRAND AVE
MASSAPEQUA NY
11758-4905
US

IV. Provider business mailing address

75 GRAND AVE
MASSAPEQUA NY
11758-4905
US

V. Phone/Fax

Practice location:
  • Phone: 516-799-3203
  • Fax: 516-799-3081
Mailing address:
  • Phone: 516-799-3203
  • Fax: 516-799-3081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: